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Using patient feedback

Qualityimprovement: thehelpyouneed

Measuring patients’ experiences of care and treatmenthighlightsareasthatneedtoimprove toprovideapatient-ledhealthcareservice.

ThePickerInstitute’squalityimprovement activitieshelpyoutoinvolvepatients,staff andthepublicintranslatingpatientfeedback intorealimprovements.

Getting startedVisit www.pickereurope.orgforpractical resourcesandmoreinformationtohelpyoucarryouteffectivequalityimprovement.

What patients wantThrough extensive work with patients the Picker Institute has identified those issues found to be most important to them:

• fastaccesstoreliablehealthadvice• effectivetreatmentdeliveredbytrustedprofessionals• participationindecisionsandrespectforpreferences• clear,comprehensibleinformationandsupportforself-care• attentiontophysicalandenvironmentalneeds• emotionalsupport,empathyandrespect• involvementof,andsupportforfamilyandcarers• continuityofcareandsmoothtransitions.

Picker Institute Europe King’s Mead House Oxpens Road Oxford OX1 1RX

Tel:01865208100 Fax:01865208101

Email:[email protected] Website:www.pickereurope.org

Registeredcharityno1081688 Companylimitedbyregisteredguaranteeno3908160

Patient feedback: helping you to improve patient experienceSection 5: Action planning for improvement

1

How can you meet tHe cHallenge of improving services in your HealtHcare organisation?

wHo tHis guide is for

tHe purpose of tHis guide

The first step is to find out what patients and service users think by asking about their experiences.

Examining feedback will give a direct insight into what is working well – and not so well – in the way your organisation delivers care. You will discover examples of good practice where lessons can be learnt, and, areas of concern where improvements can be made.

This guide is written for healthcare staff who care about patient experience and engagement and want to improve care for patients.

This guide will explain the basic principles of gathering patient feedback and provides an overview of the different methods and techniques. It outlines what to do with feedback once you have collected it in order to bring about improvements to healthcare services.

Our guidance is based on what patients say is important, and what healthcare staff tell us works effectively.

To find out more or to download the full pack, visit www.pickereurope.org © Picker Institute Europe 2009

1 Lord Darzi, NHS Next Stage Review

Introduction

USING PATIENT FEEDBACK: a practical guide to improving patient experienceSECTION 1

“ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.”1

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How to use tHis guide

wHere it works: quality improvement in action

icons used in tHis guide

acknowledgements

This guide is comprised of a number of sections, including:

>> What patient feedback is and how you obtain it

>> Understanding findings from your surveys

>> Sharing feedback

>> Action planning for improvement

>> Getting key stakeholders involved

Each section is designed to give you an outline of the topic and how it can be used, along with practical tools and resources to support implementation.

Case studies are included which show how healthcare organisations have used patient feedback to bring about improvements.

A number of icons have been used throughout this guide to help draw your attention to certain pieces of information. This is what they mean:

A key principle How to find out more

See another section in the guide

The Picker Institute is grateful to the contributions and insights from the many patients and healthcare professionals with whom it has worked on quality improvement projects and on whose experiences it has drawn.

tried and tested: by healthcare professionalstop tips

approacHes to tackling key strategic tasksstep by step

Each case study is coded according to the key principles it illustrates, using the following code:

Understandingresults/data

Involvingothers

Action planning

Communicating Linking with other work

Gathering feedback

Understanding results/data


Involvingothers

Action planning


Gathering feedback

Gathering feedback


Involvingothers

Action planning


Gathering feedback

CommunicatingUnderstanding

results/dataInvolving

othersAction

planningCommunicating Linking with

other workGathering feedback

Linking with other work


Involvingothers

Action planning


Gathering feedback

Involving othersUnderstanding


othersAction



Action planning

Using patient feedback: a practical guide to improving patient experience



Using patient feedback: a practical guide to improving patient experienceSection 2: What patient feedback is and how you obtain it

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What is patient feedback?

Patient feedback consists of the views and opinions of patients and service users on the care they have experienced. Healthcare organisations can gather patient feedback in a variety of ways including surveys, audits, comments and complaints. Staff who work directly with patients can also offer a useful perspective.

In addition, reliable evidence can be gathered systematically using a range of techniques including focus groups, one-to-one interviews and mystery shopping. It is important to select the most appropriate method for your task.

Quantitative research techniques such as surveys enable the gathering and analysis of a large number of views about certain issues. They generate numerical data about the number of people who think about a topic in a particular way.

Approaches such as focus groups and interviews are examples of qualitative research. They provide an in-depth examination of views and opinions and provide stories and narratives from the people taking part.

Why gather patient feedback?

The real test of performance by the NHS – or any healthcare provider – must be the views and experiences of its users. By asking patients in a rigorous, systematic fashion about their experiences of care and treatment healthcare services can be accurately measured and improvements made.

What patient feedback is and how you obtain itUnderstanding


othersAction




Gathering the views of patients and service users is more complex than it may initially appear. To obtain reliable, rigorous evidence the exercise must be carried out systematically.



2

Quantitative research

Patient experience surveysPatient experience surveys are the best method of gathering feedback when you want to know the views of a large number of people. They allow you to study patterns and trends and to see how common certain experiences are. They show if a problem is occurring more or less frequently over time and the types of people who seem most likely to experience it.

Questions should be developed with patients before they are used to ensure they are appropriate. Surveys can be carried out by post, telephone, online or electronically with hand-held and other devices. National patient surveysAll NHS healthcare organisations in England and Scotland are currently required to carry out postal surveys asking patients for their views on their recent experiences.

By surveying consistently and systematically these large surveys build up a detailed picture of patients’ experiences. Regularly repeating the same type of survey enables changes over time to be monitored and performance compared.

National surveys are valuable because they allow you to compare results locally against the performance of similar organisations. The results also enable regulators and policy makers to examine individual organisations and overall performance across the country.

patient experience surveys: more than just a measure of satisfaction

Examining experience Patient experience surveys ask service

users specific factual questions about what happened to them during their recent healthcare experience.

For example, ‘reporting’ style questions such as:

Did a member of staff tell you about medication side effects to watch for when you went home?

provide useful information because they highlight precisely where the problems are, and what needs to be done to improve particular elements of patient care.

Traditional ‘satisfaction’ or ‘rating’ style questions, such as:

Overall, how would you rate the care you received?

are considered less useful because they do not provide a clear indication of what needs to be done to improve care.

For instance, knowing that 15% of patients rate the service as ‘fair’ or ‘poor’ gives few clues about where to start to make the service better. Having more precise information about what went wrong, such as 23% of patients not being given an understandable explanation of their test results, is much more helpful when setting priorities for improvement.

Task

Monitoring performance and assessing quality

Determining priorities of the local population

Ongoing engagement

Identifying issues of concern to key stakeholders

In-depth investigation of attitudes and beliefs

Testing services

Public consultation

Research method

Quantitative Patient experience surveys

Population surveys

Qualitative Patient panels

Analysis of written materials

Focus groups One to one interviews

Mystery shopping Observation in healthcare settings

Deliberative events

choosing the right research method



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Population surveysSurveys of the local population can provide a detailed picture of variations in the views and experiences of local people from different geographical areas and communities. They can be designed to focus on specific issues of local importance, for example a proposed service redesign, or to obtain more general views on community priorities.

Qualitative research

Surveys highlight key areas of improvement but whilst they tell you what people think and experience they do not necessarily tell you why they feel that way.

Other approaches to gathering patient feedback can provide you with additional information to explore the issues raised by surveys in greater depth and help explain the reasons behind peoples’ experiences and behaviours.

Focus groupsGathering small groups of people together to discuss and explore their views in detail provides the opportunity to listen to a range of opinions and experiences.

Topics for discussion are identified in advance and a trained facilitator enables the group to debate them constructively.

One-to-one interviews Conversations with individual patients or users, whether by phone or face-to-face, provide detailed insights into specific issues or problems. As with focus groups, the topics for discussion are identified in advance and a trained interviewer leads the interviewee through a set of pre-determined questions.

Mystery shopping Anonymous service users can be trained as “mystery shoppers” to engage with and report back on their experiences. This can provide an accurate picture of how well your organisation is delivering services.

Observation in healthcare settings This technique involves a trained researcher unobtrusively watching and recording behaviour and interactions as they happen. It is a useful approach to investigating patient journeys, activities and processes without interfering with care and treatment.

Tailored surveys Tailored surveys enable specific areas of care to be examined in greater depth. Examples of these types of survey include:

>> community services – such as physiotherapy, podiatry, health visiting and community nursing

>> condition specific – including coronary heart disease, stroke care, cancer, diabetes and mental health

>> care settings – including emergency, inpatient, outpatient, ambulance care and day case procedures

>> patient specific – including young patients and maternity.

Alternatives to paper-based surveysMany people will be familiar with paper-based questionnaires but there are a number of alternative ways of conducting surveys, depending on where and with whom you want to carry them out. These include:

Online surveys which allow recipients to complete the questionnaire from a personal computer and submit their responses electronically

Telephone surveys which are completed with a trained researcher talking a participant through each question and recording answers on their behalf. Issues can be explored in greater depth as they arise in conversation

Hand-held electronic devices can be used for short, tailored surveys in a wide variety of situations such as on wards, in clinics or following consultations.



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Patient panels Recruiting a panel of people from the local community provides a sounding board for new ideas and an opportunity to debate and test opinion on an ongoing basis. Views can be sought using online, postal or face-to-face methods.

Deliberative events/citizen’s juries Deliberative events are opportunities for people to get together to consider and discuss complex issues in depth. They are interactive and participants are provided with information and opportunities to help share their views and concerns. Citizen’s juries work in a similar way and can be used when a decision is required from the local population about a particular issue, such as the allocation of funds or resources.

Analysis of written materials The analysis of existing written materials, such as strategies, policies and procedures, can provide a useful basis for assessing key areas of concern. It can also form an important starting point for the design of questionnaires and other feedback mechanisms which explore the issues in greater detail.

What is important to patients?

When obtaining feedback from patients and service users it is key to focus on their main areas of concern.

The Picker Institute has identified eight quality dimensions which, through work with patients, have been found to be the most important to them:

>> fast access to reliable health advice

>> effective treatment delivered by trusted professionals

>> participation in decisions and respect for preferences

>> clear, comprehensible information and support for self-care

>> attention to physical and environmental needs

>> emotional support, empathy and respect

>> involvement of, and support for family and carers

>> continuity of care and smooth transitions.

The Picker Institute recommends taking a systematic approach to gathering patient feedback:

1 set clear goals – be clear about the information you want, whether it be examining the experiences of people with long term conditions, understanding the needs of minority groups or other objectives

2 identify relevant stakeholders – be clear about who will have an interest and be affected by your plans

3 decide who you want to gather feedback from – identify the groups of patients or users you want to reach

4 secure adequate resources – ensure you have sufficient funds to invest in these skilled tasks

5 choose the most appropriate methods – be clear which techniques are right for your task, eg patient surveys, focus groups, mystery shopping or other activities

6 consider how you will act on the feedback gathered – define ‘before and after’ measures to evaluate the impact of any changes made.

step by stepgathering patient feedback: Where do you start?

To find out more or to download the full pack, visit www.pickereurope.org © Picker Institute Europe 2009 1

Careful examination of patient feedback will highlight the areas that need improvement to provide a better service for patients, and supply the evidence for change.

Patient feedback and survey results can be studied in a number of ways depending on your organisation’s priorities. Some approaches are outlined below.

ExaminE pErformancE along thE patiEnt journEy

If patients report more problems with certain aspects of the patient journey, it may be appropriate to concentrate on these areas. This could include the admission process or arrangements for leaving hospital, for example.

comparE rEsults ovEr timE

Changes in performance can be identified when surveys are repeated. It should also be possible to measure the impact of any initiatives that have been introduced.

Understanding findings from your surveysUnderstanding


othersAction




69%

2005

71%

2006

70%

2007

91%

2008

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Change in practice

The graph below illustrates how one organisation’s results improved following an initiative to improve hand washing.

As far as you know did doctors wash or clean their hands between touching patients?% Survey respondents that said ‘Yes, always’


Using patient feedback: a practical guide to improving patient experienceSection 3: Understanding your survey findings

2

Q1 Medication side effects explained to the patient

Q2 Patient told danger signals to watch for on leaving the department

Q3 Patient given right amount of information on condition or treatment

0% 10% 20% 30% 40% 50%

Low Performance High Performance% of patients being given complete information

60% 70% 80% 90% 100%

Organisation with lowest result for this question

Highest performing organisation for

this question

Short bar indicates a narrow range of responses. There is little difference between the results of the best and worst performing organisations for this question, indicating there might be less room for improvement

Long bar indicates wide range of responses and bigger difference between best and worst performing organisations on a particular issue

Length of bar indicates the range of responses

idEntify problEm arEas

Targeting areas where most patients report a problem will make a difference to a larger proportion of users of the service.

ExaminE issuEs bEing tacklEd by othEr organisations or dEpartmEnts

Exploring issues that other organisations, facing similar problems, have successfully tackled may supply you with transferable solutions and some ‘quick wins’.

To avoid re-inventing the wheel or duplicating effort, it is worth looking at issues where work within your organisation is already underway. Patient feedback may provide additional evidence to back up the need to make improvements.

lEarning from othErs: triEd and tEstEd ExamplEs

The Picker Institute’s database of good practice contains examples from organisations working to improve patient care.

Visit www.pickereurope.org to access the database free of charge.

To read about successful examples of improved patient care go to the case studies.

Intermediate 60% of organisationsWorst performing 20% of organisations Best performing 20% of organisationsExample organisation

Hospital A

Hospital B

Not at all clean Not very clean Fairly clean Very clean

0% 50% 100%

26% 42% 22% 10%

13% 34% 32% 21%

comparE rEsults with othEr organisations: ‘ExtErnal bEnchmarking’

Your national survey findings can be examined against the results of other organisations to identify where your performance is stronger or weaker in comparison.

Comparing your performance with similar services in terms of size, type, location or local population is likely to be more useful than national comparisons.

The chart above explains how to compare results against others.

comparE rEsults within an organisation: ‘intErnal bEnchmarking’

Results can also be used to identify if certain departments, clinical specialties or wards are performing better than others. If the organisation is performing particularly well in some areas it may be possible to identify the reasons why and to adopt similar practices elsewhere in the organisation.

The chart below shows how results might vary between different units within an organisation.

In your opinion how clean was the hospital room or ward you were in?


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Raising awareness is an essential part of involving patients and the public in improving healthcare services. Communicating the results of your enquiries – and what you plan to do with them – will help to ensure that they are used effectively and not forgotten.

A well planned dissemination strategy will ensure you engage all the relevant groups.

Who should you share feedback With?

Your feedback from patients – and your plans for what you will do with it – should be shared widely with key stakeholders, both within and outside your organisation.

Internal audiences include:

>> board members

>> senior managers

>> staff at all levels, in both clinical and support roles

>> volunteers.

External audiences include:

>> patients

>> public

>> local community and voluntary groups

>> commissioners

>> other healthcare organisations

>> local authorities

>> the media.

Sharing feedbackUnderstanding


othersAction





Using patient feedback: a practical guide to improving patient experienceSection 4: Sharing feedback

sharing information

Direct methods Communications that are compiled and sent directly by you have the advantage of being under your control, but your ability to reach all your audiences may be limited. Methods include:

>> events and presentations

>> direct mail – either email or paper-based

>> information on your website

>> posters

>> advertising

>> your in-house publications such as newsletters.

Indirect methods Indirect methods make use of a third party’s communications. They will help you to reach a wider audience but be aware that your material may get altered or edited to suit others’ needs or ‘agenda’. These approaches include:

>> the local media (press, electronic and broadcast)

>> dissemination in other organisations’ publications – such as your local patient groups’ newsletters

>> the health sector media.

step by stepdevising a communications strategy: the key issues

Consider each of the following:

Who you want to reach – identify your audiences and who would benefit from this information

What you want to share – establish what you want to say and whether the message needs to be tailored for specific audiences. Focus on positive as well as negative themes for a balanced view

Why you want to share the information – be clear about what you want to achieve and what you want your audience to do as a result

When and where you are going to communicate – choose a time to reach your audience when they are likely to be most receptive.

Break the activity down into ‘bite-size’ stages – inform audiences about your activities before they take place, as well as after to help prepare them and establish a positive relationship

How you will share your information – consider the best formats to reach each audience. This will vary according to their needs and circumstances.


Using patient feedback: a practical guide to improving patient experienceSection 4: Sharing feedback

those for whom your communications will need to be very carefully tailored to ensure they are included in your dissemination activities.

Some tried and tested techniques include:>> investigating local community groups and

building links with them – established groups who are working with the people you want to reach may be willing to help promote your work or allow you to attend their meetings and events to talk to their members

>> taking time to developing relationships with community leaders – aim to open up communication channels and establish trust. This may not initially involve talking about health issues directly. Ask them how they think you could share information effectively with local people

>> thinking creatively about your modes of communication – the use of pictures and modern technologies such as videos and disposable cameras may be better than the written word for encouraging two way communications with your target groups

>> considering the need for advocates or ‘buddies’ – certain people such as the young or those with communication difficulties may need help to speak for themselves, rather than through parents or carers

>> visiting schools and colleges to engage with younger people – educating younger generations in how to participate and assist in developing healthcare services may reap rewards later

>> organising informal events – lunches, coffee clubs, open days, drop-in mornings and other activities enable people to meet you and learn more in a relaxed, low key way

>> inviting community representatives to your events – or to visit your organisation to find out more about what you are doing to involve the local community

>> attending community events such as festivals, carnivals or fetes – encourage people to find out more through light hearted, fun activities such as a health quiz or a prize draw, or educational activities such as offering blood pressure testing.

content, tone and media

Tailoring your content to each of your audiences will ensure that your message has a better chance of being well received.

MediaYou may need to employ more than one format to reach everybody. You can pick from the list below according to what best suits your audience:

>> electronic – including email, website, intranet

>> paper-based – including newsletters, posters, letters, flyers

>> face-to-face – such as meetings, presentations, conferences and events.

User-friendly and accessible formatsDo your audiences have particular needs that will require tailored approaches to your materials? Consider the length of the document and whether you need to employ larger type, as well as images and graphics instead of words. Write in plain English and avoid using jargon.

Be aware that you may need to get the content translated into languages other than English.

For more information on how to make your materials accessible visit the RNIB ‘See it Right’ guidelines on their website www.rnib.org.uk

Make the information interesting

Here are a few suggestions:

>> graphs are often a better way of presenting data than tables

>> i nclude anonymised patient quotes to bring data and figures alive

>> photos and other visuals help make a document more engaging

>> highlight how people can get involved so that they feel a sense of ownership.

sharing With your local communities

To reach certain groups in the community you may need to adapt your approach and also employ more than one method of communication.

Audiences such as young people, those with disabilities, black and minority ethnic groups, asylum seekers and refugees are just some of

Your communications department may be able to offer you further advice.


Using patient feedback: a practical guide to improving patient experienceSection 5: Action planning for improvement

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Gathering patient feedback is a limited exercise unless something constructive is done with the findings to bring about improvements. Having analysed your results, you then need to decide what to do with them and where to focus your efforts.

writing an action plan

Key to success is developing an action plan with the involvement of staff and patients. It should be clear and concise whilst providing enough information to be meaningful. Make sure the language is jargon-free.

A template action plan is provided in Section 7: Useful tools

Set your goals and objectives and then divide tasks into manageable steps and achievable targets. Work out a reasonable timescale for reaching your goals along with details of how and when progress will be measured.

Incorporate relevant actions into other important organisational documents such as service improvement plans.

selecting areas for action

It is important to prioritise areas for action. It is better not to tackle everything at once, but stick to a few main priorities for action.

Choose areas that show clear potential for improvement. If plans are too ambitious they may fail so it is important to be realistic and choose approaches that are likely to succeed.

Small successes will help to keep the momentum going and encourage continuous improvement.

Action planning for improvementUnderstanding


othersAction






2

involving patients

Involving patients and service users in improvement is essential to success. Without their active participation you may not deliver truly patient-centred improvements.

Gathering feedback is only part of the process. You also need to incorporate patients’ views when acting on the findings.

Patients Accelerating Change1 is a tried and tested improvement programme run by the Picker Institute. For further information visit www.pickereurope.org

recruiting a support team

It is important to establish a group to help share the work of communicating the feedback and action planning. Work with an existing patient and public involvement group or create your own team of stakeholders to achieve your objectives.

For more advice on how to establish and work with a team go to Section 6: Getting key stakeholders involved

getting started: an action planning workshop

A workshop is a good way to kickstart the action planning process. This allows participants to explore the issues, agree on the resulting priorities and focus on the resources, time and information required to deliver the plan.

action plans: use smart objectivestop tips

Specific define what exactly is to be done

Measurable describe how you will know the action has been achieved

Achievable set realistic goals and objectives

Relevant relate the actions to ongoing work

Timebound set a date for completion

Identified issue

What issue has the survey identified? eg 25% of patients were not given enough privacy when discussing their condition with a member of staff.

Objective/Goal

What do you hope to achieve? What measurable difference will you make?

Work required

How will you achieve this goal?

Timescale

When will this be done by? Are there any major milestones along the way?

Responsibility

Who will take the lead on this initiative? Who else will be involved in making it happen?

Monitoring

How and when will progress be measured? eg audit, repeat questionnaire, comment cards

Link with other work

Are there any other initiatives that this overlaps with? Are any groups or teams working on similar/related issues?

A sample action plan

An action plan template is available for your use at the back of this guide

1 The programme was jointly developed with the former NHS National Clinical Governance Support Team



3

communicating along the way

Share your action plan widely and let others know what is being done. Communication is an important element of your action plan and will keep others informed and interested.

Including some communications activities in your plan related to key milestones and achievements will illustrate your progress.

For more advice on how to communicate effectively go to Section 4: Sharing feedback

monitoring progress

An action plan should be a flexible working document. Be prepared for circumstances to change and for future revisions to be needed. If one part of your plan is particularly successful you may want to pursue it in more depth, while if other parts are less fruitful you can scale them down.

Set deadlines and milestones and monitor progress on a regular basis. Arrange meetings to update everyone and assess how effective the changes are. This will help to maintain enthusiasm and interest.

learn from others

The issues you are facing have almost certainly been experienced by others. Find out how different organisations have approached problems and learn from their experiences to avoid ‘reinventing the wheel’.

Look internally at other departments, units and teams. They may have already made headway in certain areas, have good practice they can share with colleagues or have learnt lessons which will help you avoid making similar mistakes.

To find out more about what others have done visit the Good Practice Database on the Picker Institute’s website at www.pickereurope.org

measuring success

You need to know when you have achieved your objectives. Build mechanisms into your plan that will enable you to evaluate the impact of changes you make. Gathering further feedback will enable you to assess the impact of your work.

step by stepsuggested timetable for action planning

( before feedback gathered)

weeks Activity

4-8 – set up group of patients and staff to co-ordinate follow up work

– patient feedback collected

1-4 – analyse results and produce report

4-8 – work with group to identify areas for improvement

– organise action planning workshop

– disseminate results to staff, patients and public

– publish results via local media, posters, leaflets, website, staff bulletins, staff briefings, corporate literature etc

8-12 – where possible benchmark results against others

– hold action planning workshop

– write action plan

– set dates for monitoring progress

12+ weeks – publicise action plans

Ongoing – hold progress meetings

– publish regular updates of developments

– report on changes to services



1

A wide range of people have a ‘stake’ or interest in understanding patients’ views about healthcare services. Getting these groups involved in your activities from the start will make your task easier and will ensure the final outcomes are more successful and wide-reaching.

Who your stakeholders are

Your stakeholders are people who have a common interest in improving the services your organisation provides. This includes those responsible for delivering a patient-centred service and the local community who use it. Key stakeholders are likely to include:

>> those who govern and run the organisation – executive and non-executive board members, foundation trust governors and members

>> staff – managers, clinical staff, support staff and volunteers

>> local commissioners who purchase your services

>> patients, carers and the public – including local voluntary groups, community groups and patient representatives

Getting key stakeholders involvedUnderstanding


othersAction



>> other local healthcare organisations – they may be tackling similar issues and by working together you may be able to co-ordinate improvement strategies

>> other relevant groups – depending on the type of feedback gathered you may want to engage with particular groups such as carers and condition-specific support groups

>> your communications department

>> local authorities – including social services departments.

Why stakeholders should be involved

Everyone who plays a role in delivering or receiving healthcare services should ideally be aware of, and make use of, patient feedback.



Using patient feedback: a practical guide to improving patient experienceSection 6: Getting key stakeholders involved

2

Choose participants carefully – invite dynamic people who are keen and share your enthusiasm.

Recruit a broad cross section of people – from all relevant stakeholder groups across the organisation.

Build relationships with others – be creative about the ways you work and communicate with others to get them ‘on side’.

Secure the backing of a senior member of staff – they can help endorse the importance and value of your work. Their support is crucial for implementing and sustaining change.

Where possible delegate actions – allow those working with you to have ownership of their ideas and follow them through to delivery.

Match members’ responsibilities to their skills, strengths and interests – if someone has an incentive to participate they are more likely to fully engage with the process. Action plans should closely reflect the ability of the staff responsible for putting them into practice.

Encourage active participation to develop innovative solutions – welcoming ideas and contributions will help you to achieve far more than you could alone. The outcomes are then more likely to have a long lasting impact.

Nominate one person in each department or area – ask them to take lead responsibility for sharing the results with their colleagues.

Tailor your contact with the group to what best suits them – use face-to-face meetings, letters, emails and the web or a mixture of all these methods.

establishing a working group toP tiPsYour stakeholders can also provide the support

needed to make the improvements patients want. Commitment from front-line staff is key to implementing changes on the ground, while senior managers can help ensure quality improvement remains a priority for the organisation.

hoW to engage With your stakeholders

Approaches to stakeholder involvement will depend on the individuals involved, and what you want them to do.

Some may only need to be kept informed. Others might wish to share information or take part in some of the improvement activities.

Consider setting up a working group with whom you can maintain regular contact and delegate certain roles and actions. Be clear, however, what you want the group to do – a working group with a clear role and remit will be more successful.

Working With Patients

Think from the patient’s perspective at all times and be responsive to their needs.

Here are some suggestions that have been tried and tested:

>> pay attention to detail in your interactions with those with special needs. Small adjustments to things like communication and physical environment often make a big difference

>> consider working with volunteers who are already familiar with and supportive of your


Using patient feedback: a practical guide to improving patient experienceSection 6: Getting key stakeholders involved

3

Working With healthcare staff

‘ Buy in’ from all levels of staff is an essential ingredient to sustained improvement.

Here are some suggestions that have been tried and tested:

>> enlist senior staff support – their involvement will ensure the necessary co-operation within the organisation and help drive change

>> engage clinicians – having clinical staff involved will help encourage other healthcare professionals to support your work

>> give people a personal incentive to get involved – explain how the project will directly help them to do their job or meet their own targets. Find ways in which their involvement can help them achieve personal or professional goals

>> recruit ambassadors who can promote your work and its benefits – they may not need to have a particularly hands-on or active role in the project but will be good at telling others about it

>> think big – invite representatives from the wider healthcare community. Working across organisational boundaries may provide alternative insights and perspectives.

organisation and may be more willing to get involved. However, be aware that their views may sometimes vary from those of patients and other members of the local community

>> ensure your patient engagement is well planned and genuine – be explicit about the role of participants, what input you would like from them and jointly agree their remit. Token gestures towards involving patients will leave participants feeling disappointed

>> do not assume or try to second-guess patients’ views – listen closely to, and value, what they are saying

>> be honest – explain to patients how their views or input will affect your decisions or actions. If they cannot influence a decision then do not invite them to get involved

>> establish, and respect, how much time individuals can give – they are giving up their time so you need to continually foster – and not exploit – their goodwill. Tailor their input around the time they can offer you

>> nurture and encourage participants – some people may lack confidence or feel uncertain about their abilities to help. Support and encourage them and, if appropriate, offer advice or training

>> keep things simple and informal – remember that people may not be familiar with agendas, minutes, meeting protocol and medical jargon and might feel intimidated by them.


Useful toolsUnderstanding


othersAction




step by stepimproving patient experience: a quick checklist

Gather feedback from your patients regularly and systematically

Are you clear about what you want to find out?

Do you know who you need feedback from?

Have you made use of existing data eg national survey findings?

What other patient feedback do you need and how will you gather it?

Understand your findings

Have you examined your feedback to identify priorities for improvement?

Have you decided how to analyse your results?

Consider: aspects of the patient journey changes over time how you compare to other

organisations comparing differences within your

organisation, possibly by specialty or department

issues reported by large numbers of patients

existing organisational priorities.

Share results widely throughout your organisation and with the local community

Have you developed a practical communication strategy which identifies:

your key audiences and main messages?

ways to reach out to as many people as possible?

Action plan with service users and staff

Have you devised an action plan with clear priorities and timelines?

Do you have the support of senior managers?

Have you identified some project champions?

Are clinical and support staff across the organisation involved?

How are you involving service users in action planning?

Get stakeholders involved

Have you identified all your stakeholders and how to involve them?

Have you set up a working group?

Maintaining progress

Are you implementing some short term ‘quick wins’ as well as longer term improvements?

How will you measure the impact of your changes?

Are you confident that stakeholder involvement can be sustained throughout?

What are your plans for reporting and monitoring progress?


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Using patient feedback: a practical guide to improving patient experienceSection 7: Useful tools

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Using patient feedback: a practical guide to improving patient experienceCase studies

Where it Works

Using frequent feedback

Southampton University Hospitals NHS Trust embarked on a long-term programme of monthly patient feedback reports, led by Head of Patient Involvement, Pam Sorensen.

‘Picker’ surveys using hand-held devices are completed by patients in a full range of clinical areas from emergency admissions to specialist care.

Results are combined with all other patient reports, including complaints and PALS, building up a strong set of information that helps identify trends.

The monthly results are shared across the hospital to help Southampton achieve its overarching vision of putting patient experience at the centre of quality.

A number of divisions are working on an ongoing action plan to bring about a range of service improvements, which includes:

performance monitoring by the trust’s governance team which makes regular use of the findings. The Performance Tree system, which is actively used by the board and senior managers to monitor the overall performance of the trust, now includes results from the questions on ‘overall satisfaction’ and ‘would you recommend the hospital to others?’

identifying dips in satisfaction and their causesto help work out when and why patients are less satisfied with their care and treatment, and to ‘nip problems in the bud’. Dips in patient satisfaction ratings, for instance, have been found to coincide with periods when the trust is exceptionally busy

sharing results with commissioners, the public and other audiences to illustrate the trust’s commitment to improving standards. Plans are underway to develop ward display boards to present results and intended improvement measures, as well as an article in the trust’s magazine

improving patient information which has been highlighted by the feedback as a weakness across the trust. Work is underway, particularly in pre-admissions, to tackle this issue

boosting staff morale by sharing the results from frequent feedback surveys which are, in the main, more positive than those from national surveys

localised initiatives to bring about specific service improvements, including:

>> better signage around the hospital site – implemented by the estates division

>> training in the principles of customer care for all staff

>> improvements to the appointments system – implemented with the help of the IT department.

“ Each division and care group can see what people are saying about a particular service which makes feedback much more focused, specific and relevant for our staff.” Pam Sorensen, Head of Patient Involvement


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“ Staff initially assumed that the feedback would be negative, but in fact it’s often very positive about the service and those providing it.”

Pam Sorensen, Head of Patient Involvement


1 Developed with the former NHS National Clinical Governance Support Team


The Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust (RDaSH) used their results from the NHS Community Mental Health Survey to examine and improve their performance on the Care Programme Approach (CPA).

The CPA helps service users and carers play an active role in their care rather than act as passive recipients. By comparing survey results from previous years and that of other trusts RDaSH realised their performance regarding the CPA had slipped.

GettinG started

A CPA Improvement Group was created as a sub-group of the trust’s User/Carer Partnership Council which aims to maximise service user and carer involvement in all trust activities. The group, made up of service users, carers and the Public and Patient Involvement Lead, wanted to ensure that they tackled the issue collaboratively. The group joined the Picker Institute’s programme, Patients Accelerating Change.1

settinG priorities

The Improvement Group identified particular questions from the survey as indicators of key priority areas for action, including:

>> have you been given (or offered) a written or printed copy of your care plan?

>> do you understand what is in your care plan?

>> were you involved in deciding what was in your care plan?

action planninG

The group’s work took the following path:

1 research into best practice led them to the work of North Essex Mental Health Partnership NHS Trust, who had developed a care plan

folder for service users. Following contact with their CPA lead, RDaSH decided to develop their own

2 development of a care plan folder providing written information on CPA and a place for keeping copies of care plans and other relevant information

3 piloting of the folder to service users who were on enhanced CPA

4 further development and distribution based on an action plan written and agreed with stakeholders. An initial 1500 copies of the folder were distributed

5 evaluation of the folder by the research sub-group of the Partnership Council included a questionnaire sent to a random sample of people registered on enhanced CPA. The evaluation showed that where people had received the folder it was valued and was seen as an improvement in service delivery

6 following the evaluation there have been some amendments to the text; service managers have reinforced to care co-ordinators the need to use the care plan folder as part of communication about the CPA and a further 1500 folders are to be distributed across all adult services.

achievements

The folder enables service users to keep a written record and other documentation in one safe place.

The project has raised staff awareness of the need to proactively provide service users and carers with high quality information about the CPA and use the folder as part of a wider information-sharing process.

“ Being involved in this process has empowered me to challenge what has been written in my care plan and make changes that reflect my needs.”

Member of the RDaSH CPA Improvement Group


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Improving mental health services

Where it Works



Where it Works

Staff from the Emergency Department (ED) at Harrogate District Hospital used a Picker Institute action planning workshop as a springboard for implementing both some ‘quick wins’ and longer term improvement plans.

Learning and collaborating with others

Stephanie Davis and ED Sister, Cathy Franks, used the action plan tool (see template in Section 7) from the workshop along with suggestions from other participants, and adapted them for their own use.

involvinG others

The first step was raising awareness of the importance of patient feedback. A fun quiz at a multi-disciplinary staff ‘time out’ day about the latest set of survey results helped engage colleagues in a light-hearted way, yet also communicated a more serious message about the need to improve.

straiGhtforward but effective quick wins

A careful walk around the department ‘through the eyes of a patient’ highlighted a number of issues raised by patients. Quick wins were achieved with relatively uncomplicated actions, some based on ideas from the suggestion box, including:

new laminated “care in progress” notices easily attached to curtains with a peg, to help protect patients’ privacy

improved signage to help patients find key locations such as the toilets. Laminated wall signs were created by department staff while the estates department provided larger free-standing signs

replacement of the word ‘triage’,which is not widely understood by patients, with ‘patient assessment’ on such things as door signs. Patient information about the triage process was also made more user-friendly with laminated posters providing explanations

pain assessment badges saying “Are you in pain?” introduced for staff to encourage patients to ask for pain relief if needed. Posters with the same message were also put in all the patient cubicle areas

a coloured chevron line marked out in reception to help create an exclusion zone around patients giving confidential details to staff

posters encouraging patients to ask when they need refreshments.

lonGer term solutions

Larger improvement projects in progress involve other departments in the trust and include:

replacing curtains in two cubicles with a solid partition to improve patient privacy

incorporating customer care training in the staff induction programme to help improve communication skills and awareness

a review of information on medicines – the trust’s pharmacist is working with Stephanie to produce patient information on a range of topics including eyedrops, analgesics and antibiotics. The pharmacist is in turn consulting other trusts about what they do

combining complaints and PALS leaflets into one single, easy-to-follow version

‘feedback’ posters outlining the ways in which patient feedback has been acted upon

the possibility of physical changes to the reception area to improve privacy and dignity for patients attending reception.

what’s next?

In addition to seeing through all the longer term improvements, Stephanie is considering introducing a regular small scale survey to measure the impact of the initiatives against the performance of other trust departments.

“ Learning how other trusts have tackled problems – and working collaboratively to find solutions to suit our needs – has avoided wasting time and resources ‘re-inventing wheels’.” Stephanie Davis, Modern Matron, Emergency Department


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The Shrewsbury and Telford Hospital NHS Trust has gone to considerable lengths to share their patient survey results with staff, patients and the public.

Wide dissemination of survey results

Dissemination techniques include:

presentations at Board meetings open to staff and patients

newsletters, team and chief executive’s briefings to all staff

the corporate induction programme for all new staff which now includes a section about the national survey programme

presentations to a number of different staff groups that include clinicians and managers. These events are used as an opportunity to highlight areas worthy of praise as well as those needing improvement

Each presentation is specially tailored to the needs and interests of those staff attending. Patients’ comments are used to illustrate the story told by the data and have been particularly useful in highlighting issues such as noise in the wards at night and helping patients to eat

presentations about new policies and other initiatives often now contain patients’ comments, both positive and negative. For example, patients’ comments have been used in presentations about the new hospital consent policy and in the promotion of good hand hygiene.

GatherinG further feedback

In response to requests from staff for local feedback, teams now carry out regular local surveys which provide immediate feedback on issues of concern.

This local survey programme builds upon the national survey themes and feeds into a ward-based performance dashboard.

Real improvements have been seen in the results from these surveys over the two years since their introduction.

involvinG others

The trust has also sought to tackle the issues that have been raised by involving local groups. They include:

the Community Engagement Forum with whom information on both the national and local surveys has been shared, generating many ideas for service improvement

working groups of volunteers who have been established to concentrate on specific problem areas highlighted by the surveys, such as food and discharge planning, have resulted in improvements in these areas.

“ Survey results, and the main themes arising from them, are disseminated in a broad range of ways.”

Clare Jowett, Head of Risk and Assurance


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A survey and a series of focus groups became the launch pad for a dynamic user group in the cancer services directorate at St George’s Healthcare NHS Trust in London.

The Improving the Cancer Experience (ICE) group is now actively involved in bringing about improvements to patients’ experience of cancer treatment and care.

Building genuine patient involvement

creatinG the Group

Membership is predominantly made up of patients, recruited from an open evening held for the survey and focus group participants, along with a small number of healthcare professionals.

A start-up meeting was held, led by an external facilitator, to determine the role and objectives of the group, establish ground rules and identify the skills and interests of members. A chair and secretary were nominated while the Lead Cancer Nurse worked to nurture the group’s development.

actions and achievements

The group have initiated a range of improvements by working in partnership with professionals in the trust including:

unrestricted internet access on wards to enable patients, particularly younger and long stay ones, to stay in touch with friends and family via the internet and feel less isolated

development of a ‘home care’ pack to help patients cope after discharge. Survey feedback highlighted the need to improve patient information on coping at home

meetings between the group’s chair and the trust’s chief executive to share patient concerns

attendance at the cancer clinical directorate meetings to contribute the patient perspective and raise the profile of service user feedback in the trust’s day-to-day operations.

tips on establishinG an effective user Group

Members of the ICE group offer the following advice:

>> establish some guiding principles to steer the group’s activities

>> recruit members willing to get actively involved

>> appoint a strong chair who can help lead the group

>> provide training and support for members where needed

>> encourage members to look out for opportunities where their involvement would be beneficial

>> create working groups for projects that report back to the wider group

>> adopt a champion to help promote genuine service user involvement and raise the profile of the group within the trust

>> give the group time to evolve – it may need to find its feet and ‘gel’ before it becomes an effective body

>> build up links with external bodies – ICE have had involvement in the regional cancer network and access to training by Macmillan Cancer Support

>> get the balance of membership right – having more lay than professional members will help foster user ownership of the group

>> be clear about the group’s role to avoid confusion with that of a support group.

“ It’s rewarding being empowered to work with professionals to actively improve the experience of cancer patients of the future.”

Valerie Emmons, Secretary to ICE


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Documents

Using patient feedback - NHS Surveys find out more or to download the full pack, ... Using patient feedback: ... complete the questionnaire from a personal